Infection Control in Robotic-Driven Operating Rooms

April 1, 2001

Infection Control in Robotic-Driven Operating Rooms
New OR Designs Support Automation and Help "Keep It

By Scott Hazlett, AIA

in technology continue to drive increased automation in the OR. The trend toward
minimally invasive surgical procedures in robotically equipped ORs is helping to
create a faster, safer, and more efficient surgical environment. However, this
trend and the benefits it brings does not alter the need for continued vigilance
from the standpoint of infection control. How can the individuals charged with
infection control in the OR prevent a hospital-acquired infection from
overshadowing the benefits of minimally invasive surgery? Fortunately, many of
the design and engineering features developed to accommodate automation along
with minimally invasive procedures have made it easier to keep ORs clean and
infection free.

The recently completed two-room Minimally Invasive OR Suite project at the
University of Pittsburgh Medical Center (UPMC) in Pittsburgh, Pa, will serve as
a case study for addressing design for infection control in a newly designed
robotically-equipped OR. Designers considered important elements including the
size of spaces, equipment selection, finishes, HVAC, and lighting. Individually,
each of these items is important, but when all are brought together in one
space, the result is a state-of-the-art surgical facility that provides the best
possible environment for control of hospital-acquired infections.

Space Helps Reduce Cross-Contamination

The key design concept that helps provide infection control is adequate
separation. In the past, ORs were smaller and facilities were closer together,
which promoted cross contamination. In the recent project at UPMC, ORs were
designed to be large (550-600 sq. ft.), allowing greater separation between the
sterile field and the non-sterile perimeter that houses computers, supply carts,
trash carts and other items that do not enter the sterile field. Patients and OR
staff members access the ORs through separate entrances to avoid cross
contamination of a scrubbed surgical team member and the transport personnel and
stretcher. There are no floor penetrations for power or medical gases, and all
wall and ceiling penetrations are sealed.

One design feature that was especially important to UPMC is an observation
gallery that is situated between the two ORs. "Having the observation room
means that we have minimized the number of people who are going in and out and
that definitely impacts infection control," says Paulette Bingham, director
of the ORs at UPMC Presbyterian. "Because we are a teaching hospital,
students still need to be able to watch and listen to the surgeons. With the new
technology, it's like being in the room but without the increased risk of

Specialized Instrumentation Reduces Contact Transmission

UPMC selected advanced hands-free or voice-activated surgical equipment to
eliminate the need for surgical team members to touch equipment that may be
contaminated. The rooms were designed to accommodate the latest Hermes
hands-free communications technology and robotic surgery equipment such as AESOP
and ZEUS. Multiple cameras in the ORs can provide live video to other locations
for consulting and teaching purposes. Hands-free telephone equipment and
voice-activated devices, such as OR tables that can be raised or lowered by
voice command, help reduce contact transmission. Touch screen computers are used
instead of keyboards.

Bill Phelps, a Facility Planning Specialist at UPMC Health System's Oakland
campus in Pittsburgh, notes that integrating all of the automated technology
into a seamless system was a key priority for this project, and infection
control was always at the top of the list. "Video, voice, and robotic
capabilities have been a tremendous asset," says Phelps. "Many of the
tasks that previously required operating hand controls or typing on a
keyboard--to adjust the lights or raise the table, for example--have been
replaced by simple voice commands. This helps preserve the sterile field and
makes for a much more efficient flow of personnel around the table, and to and
from storage and support equipment," says Phelps.

Ceiling-hung equipment booms hold equipment up off of the floor, which might
otherwise be cluttered with carts. All utilities and medical gases originate in
the ceiling-hung equipment booms, eliminating hoses and cables running across
the floor from the non-sterile into the sterile zone like strands of spaghetti.

"The boom technology clears floor space, so it's much easier to clean
and disinfect the floors properly without having to relocate a lot of
equipment," says Phelps. Booms also make it easier to organize power,
medical gas, and electronic cabling to minimize the number of dust-gathering
accessory lines.

Finishes HVAC and Lighting Enhance Infection Control

Special attention was given to finish selections to provide for ease of
cleaning and durability. An epoxy terrazzo floor with integral base (no joints
or seams) and ceramic tile walls were selected because they are easy to clean
and resist damage from harsh cleaning solutions. Epoxy-based grout is used with
the ceramic tile to prohibit moisture absorption and bacteria growth. Ceilings
are made of seamless gypsum wallboard and sealed with epoxy paint. The paint
used on metal and gypsum board surfaces is an anti-microbial epoxy paint used
for durability and to limit bacteria growth. OR storage cabinets are made of
stainless steel and glass for easy cleaning. Sealant is installed around all
wall penetrations and joints between dissimilar materials to ensure that the
finishes form a continuous seal around the room.

The control of airborne contaminants in an OR is an essential component in
controlling transmission of infection. At UPMC, the HVAC system has been
designed to meet the latest federal guidelines for air filtration, outside air,
and air change requirements. The laminar flow HVAC system delivers air from the
ceiling around the surgical table and exhausts it through low exhaust vents in
the room's corners to provide a clean air curtain around the sterile field where
the patient is located. Positive air pressure in the room keeps unfiltered
non-OR grade air from entering the room through open doors. All ductwork
delivering OR-grade air to the surgical suite is insulated on the exterior to
eliminate surfaces inside the ductwork on which molds and bacteria can grow.
Ductwork with insulation on the inside is no longer used in hospitals.

Even the OR lighting plays a role in safeguarding the patient. The lighting
levels can be adjusted by voice command during surgery, eliminating the need to
touch hand controls. With so many lighting levels available, room brightness can
also be adjusted to make cleaning easier and more thorough. Finally, gaskets and
seals on overhead light fixtures promote dust control and prevent air
infiltration through the fixtures from adjacent spaces.

Many design and engineering features of robotically equipped, minimally
invasive ORs actually help promote infection control, making the jobs of those
responsible for assuring a sterile environment easier. The concern that the
constant addition of technology to the OR might compromise the staff's ability
to provide adequate infection control is unfounded. Bingham says, "The way
the rooms were designed has a big impact on our ability to maintain a sterile
environment. They are easy to clean and we can turn them around faster. With the
new technology all of the timeframes are shortened. Because the surgeon can
operate many of the systems by voice command, everything moves quicker. This
means the patient is open on the table for a shorter period, and the risk of
infection is lowered."

As technology continues to improve and the numbers of procedures that reduce
the risk of harm to patients keep growing, the ability to provide infection
control will also continue to improve.

When the architect, engineer, surgical staff, and infection control
specialists work together on the design of an automated, minimally invasive OR,
the end result is helpful to the patient. Patients enjoy a faster recovery and a
smaller risk of contracting a post-operative infection that could be worse than
the problem that required the surgery in the first place.

Scott O. Hazlett, AIA, is a senior associate with Burt Hill Kosar
Rittelmann Associates, an architectural and engineering firm with offices in
Butler, Pittsburgh, and Philadelphia, Pa; Boston, Mass; and Washington, DC.

His recent healthcare sector work includes projects at UPMC Presbyterian,
UPMC Montifiore, and Magee-Women's hospitals in Pittsburgh, Pa; East Liverpool
City Hospital, East Liverpool, Ohio; Veteran's Affairs Medical Center, Erie, Pa;
and Westmoreland Regional Hospital, Greensburg, Pa.

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